BLOOD, TRANSFUSION of. — The first mention of a transfusion of b., although performed by taking the b. by mouth, may already be glimpsed in the works of Pliny, in the anatomical treatise of Herophilus, in Book VIII of Ovid’s Metamorphoses, and also in ancient Hebrew texts.
In the chronicle of Rome written by Stefano Infessura, it is stated that in 1492 a Jewish physician attempted to transfuse into the veins of the ailing Innocent VIII, with the aim of restoring him to health, the b. of three ten-year-old boys; the episode, however, cannot be historically verified and is specifically denied by Pastor in his History of the Popes.
The first certain report concerning transfusion dates only from 1667, when a certain Denys, professor of mathematics and philosophy in Paris, is said to have made the first attempt to introduce lamb’s b. into a demented boy for therapeutic purposes. The experiment, performed by directly connecting the two vessels by means of a silver cannula, was successful; but this practice, although finding numerous supporters throughout the world, was often opposed both by physicians and by civil and religious authorities, partly because of the frequent failures and partly because of moral and legal prejudices. Indeed, in 1669 both the Supreme Court and the French Parliament, as well as the Holy See, prohibited the practice of transfusion, considering it an immoral act.
After alternating vicissitudes, it may be said that transfusion began to establish itself only in the second half of the nineteenth century through the work of scientists throughout the world: Prevost, Dumas, Karst, Bischoff, Carrel, Gille, Sabbatani, and especially Landsteiner, discoverer of the blood groups. At present transfusion has entered medical practice, not only for the purpose of replacing a possible severe loss of b., but also for therapeutic purposes in various morbid conditions. It now appears established, in fact, that transfusion, besides replacing lost b., possesses a mobilizing action on the blood reserves, a tonic action on the peripheral circulation, as well as hematopoietic, antihemolytic, hemostatic, antitoxic, and anti-infective effects, in addition to an organotherapeutic action.
Normally transfusion may be performed with homologous b. (taken from individuals of the same species), with b. derivatives (plasma, serum, concentrated red or white blood cells...), with heterologous b. and plasma (taken from beings of a different species), or with artificial solutions used as substitutes for b. Nowadays transfusions are practiced almost exclusively with human b. or its derivatives, animal-b. transfusions having been abandoned.
Among the methods in use, the following must be considered: a direct transfusion (the b. passes directly from the donor to the recipient by means of special equipment); an indirect transfusion, used more frequently today following the discovery of the anticoagulant properties of sodium citrate by Sabbatani in 1902 (the b. is first collected in special containers or flasks containing anticoagulant substances, where it may be preserved for three, four, or five days). In addition to these two methods, transfusion of preserved b. taken from cadavers should be mentioned; this b. has the advantage of no longer possessing the capacity to coagulate and of being preservable for three to four weeks. The method was introduced by Judine in Moscow in 1930. In the United States, studies are under way to achieve long-term preservation of b., without alteration of its components, through coagulation.
Although it has entered everyday medical practice, transfusion still has the character of a procedure of some importance, and must therefore engage the physician’s responsibility with regard both to its indications and contraindications, and to the preservation and selection of the b., as well as to its technical execution.
The principal problem at the present time is the selection of the b.; this is governed by the rule that: “the recipient’s b. must not contain antibodies that act upon the donor’s red blood cells.”
Landsteiner in 1900, and a few years later Jansky and Moss, discovered the well-known “blood groups,” classifying all human beings into the groups: A, B, AB, O (zero), according to the presence or absence of certain “antigens” (agglutinogens) contained in their red blood cells and of certain “antibodies” (agglutinins) present in their plasma. If the donor is not selected appropriately, an encounter may occur in the recipient’s b. between an agglutinogen and an agglutinin of the same name (e.g.: the donor’s red blood cells with agglutinogen A and the recipient’s plasma with anti-A agglutinin), resulting in severe reactions and even danger to the patient’s life. Hence the absolute necessity of determining with the utmost care the donor’s belonging to the different groups and of taking their respective tolerances into account before performing a transfusion. At present the number of blood groups has increased considerably, both through the discovery of new systems (MNS, P, Kell-Cellano, Rh, Lutheran, Leway, Jobbins, etc.) and through the identification of numerous subgroups. In practice, however, from the transfusional point of view, only the ABO system and the Rh system, discovered by Landsteiner-Wiener in 1940, are important. The importance of the Rh factor has now become so great that, from the legal point of view, a physician is considered duty-bound to transfuse Rh-negative b. in many cases, especially in young women, since a possible transfusion with Rh-positive b. could cause serious alterations in the event of pregnancy affecting the fetus, should the latter present in its b. the characteristics of an Rh-positive type of paternal origin. In some of these cases, if the fetus reaches term, the newborn displays the characteristics of a particular disease: “fetal erythroblastosis,” which is treated solely by the so-called “exchange transfusion,” or total replacement of the b. (v. PATERNITÀ, ricerca della).
In selecting the donor, in addition to group incompatibility, the danger of transmitting certain diseases through transfusion must be borne in mind: malaria, syphilis, and especially epidemic hepatitis (unfortunately often unavoidable unless b. sterilized with radium or highly ionizing rays is used).
Regarding the dangers of transfusion, the possibility of local and general reactions arising even after the appropriate group has been selected must always be kept in mind. The mortality rate varies considerably according to the authors: Tzanck gives a rate of 1/300, Bazzocchi and Bendandi 1/2500; Domenici had no deaths in 10,500 cases.
Most jurists today consider transfusion a lawful act, even without the donor’s consent, provided that it is necessary in this way to save a person from an “immediate danger of serious harm, not otherwise avoidable.” Nevertheless, the law, for example in Italy, provides that the physician’s responsibility must be invoked in cases of: performance despite contraindications (severe cardiac, renal, or hepatic lesions...), failure to perform it in the presence of absolute indications (severe hemorrhage), incorrect selection of the b., and technical errors (D. M. 20300/2 of 3 June 1935 and of 13 Dec. 1937).
From the moral point of view, the donation of a portion of one’s own b. must be considered lawful provided that the amount withdrawn is not such as to endanger the donor’s life or cause serious harm to his health (v. MUTILAZIONE). In particular circumstances, when it represents the only possibility of saving an individual from death, refusing, without the reason of serious harm to oneself, to donate a fair portion of one’s own b. constitutes a grave offense against charity. On the other hand, a physician may not take b. from an individual, or take more than the amount of which he is aware, for the purpose of using it in transfusion, without that person’s consent.